Q banks collection
Read all scenarios for history taking from Ryder Mir volume 2. Other books to refer to are Success in PACES by Philip Kelly and PACES for the MRCP by Tim Hall.
History taking: when you read the scenario:
1. make a list of differential diagnosis, most are given in that scenario discussion 2. for each differential diagnosis find out which questions to ask to rule it out 3. learn what are the alarm symptoms for each system of the body 4. make a problem list as you go on taking history, note on the paper Now how to tackle the history taking:
When you practice history taking with a colleague:
Read the scenario carefully and on a piece of paper make notes where you write down important points from the scenario and make a structure for taking history like:
1. Introduce yourself and confirm identity of patient: “Mr Wilkin’s?” The patient will say yes or will nod. Say, “Nice to meet you.” I am Dr Candidate, I am a Senior House Officer in ER/ Admissions unit/ Cadiology/ Gastroenterology unit.
2. Verify the information with the patient by saying that your GP has written this letter saying that you are 54 years old and you have chest pain for the last 2 months plus any other information – the examiner marksheet has marks for this especially. Just remember that what the GP has written may not be true, so it is important to verify. And GP’s suspicions about the patients diagnosis may not be true either.
3. Hx of presenting complaints: Always start with an open question like, “Your GP has written so and so, tell me more about it”. Take detailed history about the presenting complaint like, breathlessness, pain, fatigue, etc. E.g., full history of pain: site, nature, character, intermittent or continuous, severity, radiation, whether is the same, improving or deteriorating, associated symptoms and its effect on the patient’s life. Alarm symptoms like wt loss, bleeding, etc. 4. Previous investigations: it is good idea to ask the patient about this because it reveals further information which the patient has not yet revealed.
5. Systemic review and alarm symptoms plus menstrual history for women. One by one rule out all diseases from your list of differential diagnosis, like joint pains and hand deformity in rheumatoid arthritis, any silvery/scaly rashes for psoriasis.
Alarm symptoms: Pt with cancer: symptoms of cord compression, hypercalcemia (polyuria/polydipsia), superior vena cava obstruction (swelling of face) and neutropenia (frequent infections).
Liver diasease: symptoms of ascites, melaena, confusion and jaundice.
Heart disease: symptoms of chest pain at rest, syncope and family h/o sudden death.
Abdominal pain: symptoms of wt loss, jaundice and family h/o intra-abdominal malignancy.
Back pain: h/o loss of bladder or bowel control, leg weakness.
6. Past Hx of relevant or any other diseases including ongoing complaints: diabetes, asthma, angina, heart attack, high blood pressure. Any surgeries. Any relevant travel history.
7. Drug Hx and allergies: Any drugs, whether effective or not. Any side effects. Keep in mind any drugs which maybe causing the patients symptoms, like, diuretics causing falls (postural hypotension), amiodarone causing thyrotoxicosis or hypothyroid symptoms, etc.
8. Family Hx: of similar or any other disease. Diabetes, asthma, angina, heart attack, high blood pressure. Parents, early death in family due to heart disease in relevant cases. Family h/o sudden death, etc
9. Social Hx: marital status, occupation – relate occupation to the patient’s symptoms, social circumstances. Stairs, etc., in the house in case of mobility problem. Any assistance at home, any dependents.
Smoking: do you smoke, if “no”, then if you have ever smoked, how many cigarettes, for how long, when did you stop. If “yes”, then have you ever tried or thought about quitting.
Drinking: if denies heavy drinking but you suspect symptoms to be drinking related, then ask the CAGE questions: C – have you ever tried to cut down on your drinking? A – have you ever felt annoyed if others criticize your excessive drinking? G – Have you ever felt guilty about drinking too much? E – do you feel like having a glass of alcohol early in the morning ( eye opener)?
Illicit Drug History: marijuana, injecting drugs, sharing needles.
Sexual History: If relevant. Partners, contact with prostitutes, homo-hetero sexual. Unsafe sex, especially during travels to sub-Saharan Africa
10. Patient’s Concerns/beliefs/insight: What do you think your symptoms are caused by? Do you have any concerns? Do you have any questions? It is very important to address any concerns of the patient. Does the patient really understand the severity of the disease? They may ask “do I have cancer, doctor?” You need to talk to them appropriately. You must not rush this part.
11. Summarize, explain plan, and any follow up arrangements
12. Create a problem list including management plan
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